1. A nurse in a long-term care facility is assisting with an in- service for newly hired assistive personnel about legal issues within the facility. Which
... [Show More] of the following should the nurse include as an example of assault?
ANS: Informing a client the nurse is going to administer an injection even though the client refuses.
2. A nurse is collecting data from who is severe pain. Which of the following questions should the nurse ask first?
ANS: "Where is your pain located?"
3. A nurse is reviewing the laboratory results for a client who is at 29 weeks gestation. For which of the following results should the nurse notify the provider?
ANS: Platelet count 95,000 mm3
4. A nurse is performing a dressing change for a client who had abdominal surgery 5 day s ago. The nurse notes organs protruding from the incision. Which of the following act ions should the nurse take?
ANS: Cover the exposed area with sterile, saline-soaked dressings.
5. A nurse is speaking with the adult daughter of a client who has Alzheimer's disease. The daughter states, "I love my dad, but caring for him is wearing me out." Which of the following response should the nurse make?
ANS: "Let's discuss how caring for your father is affecting your health.
6. A nurse is contributing to the plan of care for a care for a client who has chest tube co nnected to a closed drainage system. Which of the following actions should the nurse i nclude in the plan of care?
ANS: Maintain the drainage system below the level ofIthe client's chest.
7. A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports. "I am going to kill my girlfriend when I get out of here." Which of the following actions should the nurse take?
ANS: Notify the client's care team of the threats against the partner
8. A nurse is admitting a client who is at high risk for suicide. Which of the following actions is the nurse's priority? ANS: Search the client's personal belongings
9. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. W hich of the following actions should the nurse take to promote the client's venous return?
ANS: Maintain the sequential compression device.
10. A nurse on an acute care unity is collecting data from a school- age Child who has cystic fibrosis. Which of the following findings is the priority for the nurse?
ANS: Reports lack of appetite
11. A nurse working in a provider's ofollowingice receives a phone call from the parent of a school-
age child who has varicella. The parent asked the nurse when the child can return to school. Which of the following responses should the nurse make?
ANS: "When the lesions have scabbed over."
12. A nurse in a pediatric clinic is collecting the data from a school- age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take? ANS: Report the suspected abuse to an appropriate agency.
13. A nurse is collecting data from a middle adult female client who is taking melatonin.Which of the following responses to the med should the nurse expect?
ANS: Improved sleep
14. A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention? ANS: A school-
age child who has allergic rhinitis and is taking diphenhydramine.
15. A nurse is preparing to administer purified protein derivative (PPD) to a client who ha s suspected TB. Which of the following actions should the nurse plan to take?
ANS: Ensure the injection produces a wheal on the skin
16. A nurse in a pediatric clinic is collecting the data from a school- age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take? ANS: Report the suspected abuse to a appropriate agency.
17. A nurse is collecting data from a middle adult female client who is taking melatonin.Which of the following responses to the me [Show Less]